GW1--07666_Well Construction - GW1_20231204

f
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: '
Cjn r\ r)r) IA i Ifs 14:WATER ZONES_ _
Well Contractor Name FROM TO DESCRIPTION
(� 1 2b ft., ft
� ) 1 , G 2avft. ft.
NC Well Contractor "fication Numberf /*� 15'OUTER:CASING.(formul4-cssed'wells)OR 1.1NER(d ap"4cable)
1 �k 5 \'C 1. Dri
I I ( , r FROM TO(J� D/IA_METER THICK/NNESS MATERIAL
C any NameIJ�J ( N q ©ft. I 1 J f E ( 11 4 4 i . 1 pV
. �l1 � J '16cINNERCASING!ORTUBING(geothermahclosed=loop) .;<
2.Well Construction Permit#: V� FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable well construction permits(l.e.UIC,County,State.Variance,etc.) ft. ft in.
3.Well Use(check well use): ft •ft in.
Water Supply Well:
17SCREEN :'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural . ❑Munigipal/Public ft ft. ;in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft is
❑lndustrial/Commercial ❑Residential Water Supply(shared)
`
❑hrigation " ❑Wells>100,000 GPD FROM TO1 rMATERIAL' _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft .2O R• Ike -iln . T c2fLi t-P C:,
❑Monitoring ❑Recovery ft. ft.
Injection Well: '
ft. ft.
❑Aquifer.Recharge ❑Groundwater Remediation
19 SAND/GRAVEL,PACK(Ifapplicable) _.
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer •'20 DRILLING hOG(attach additional sheettlfnecessai•y) .,. .:• :':
FROM TO DESCRIPTION(color,hardness,soinrock type,grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) b [ �j
I ft. I ft ,�roa t 1. ,,
4.Date Well(s)Completed:mil \7-•t— Well IN/ /II 0 f. zi 0 it
n c'Gy /SC*l�lek,4-o/1e"
5a.Well Location: .. -/b ft /D® ft P 14- 9 r•G 1
5 FbrcV Ind ft. S ft- Glue_ s IA+e- o
Facility/Owner Name Facility ID#(if applicable) ft. ft.
i. �� `
? I I I 1 ecY) c ft ft. r -rt"',-. _
Physical Address,City,and Zip ft. ft.
VI �12�1 1 1 1 �" a ! 21'REMARK3 . .` . . }}(':f< .r.`i-l'LJ
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 0`'`i'�,
(if well field,one lat/long is sufficient) 2 Ctt 'frcation:
'3S‘i%-trk-I 21/4'1 N eOrCil8,41i W 4 A/'. 1` c
:0
6.Is(are)tiid'well(s): 4/Permanent or ❑Temporary Signature f Ce ified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.with
7.Is this a repair to an existing well: ❑Yes or 11allo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to thew!!owner.
, repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dulled:, L�/ `'� 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: vJ (ft) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200' 2®100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)10.Static water level below top of casing: (((��� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'•r
I
11.Borehole diameter: Q (I)? (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
II Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r VC 4 i IA-3 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
1
FOR WATER SUPPLY\ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) —1 Method of test: OA r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 0,T4 Amount: \ jpi-